306005322-7-18-2024-22-AS-EKIM-D7AVHQ-20240718162731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005322
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:27:37 PM

Document Has Been Signed on 07/18/2024 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ACTIVCARE AT YORBA LINDA		FACILITY NUMBER:	306005322
ADMINISTRATOR:	ELVA LEDESMA		FACILITY TYPE:	740
ADDRESS:	4725 VALLEY VIEW AVE		TELEPHONE:	(714) 577-8005
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	60	CENSUS: 38	DATE:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Enrique Ledesma		TIME COMPLETED:	04:45 PM

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On July 18, 2024 around 8:25AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Enrique Ledesma and explained the purpose of the visit.

The facility is licensed to operate for sixty (60) non-ambulatory, of which 15 may be bedridden, and have a hospice waiver for fifteen (15) residents. Facility is approved for delayed egress and secure perimeter, and a waiver for locked perimeter gates. The facility is a single-story structure, which consists of the following: fifty-three (53) resident bedrooms, six (6) office rooms, thirty-eight (38) bathrooms, waiting area, activity area, dining room, kitchen, and two (2) outdoor covered patio areas.

LPA Kim toured indoor and outdoor of the physical plant with ED Ledesma. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 101, Resident Room 106, Resident Room 206, Resident Room 209, Resident Room 306, Resident Room 307, Resident Room 310, Resident Room 401 and Resident Room 409. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 107.2 degrees F and 114.9 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 07/18/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Emergency food is stored in the kitchen. Emergency water and emergency supplies were stored in a storage closet. A working telephone (714-577-8005) remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on April 22, 2024. The facility has eleven (11) fire extinguishers that are charged and they were all serviced on September 22, 2023, smoke detectors, and carbon monoxide detectors were operable and last checked on November 7, 2023. First Aid was maintained and contained all the necessary elements.

LPA Kim conducted an audit of ten (10) resident files (R1-R10), eight (8) staff files (S1-S8), and medication and medication administration record were all in order and complete. LPA conducted three (3) resident interviews and seven (7) staff interviews.

A Technical violation was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided to Executive Director Enrique Ledesma.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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